Monday, 6 June 2016

[NOTE: I WILL BE IN CHINA UNTIL JULY, NO BLOGGING UNTIL THEN. IN THE MEANTIME, HERE'S MY ARTICLE FROM MY DAY JOB]:

The Chinese have a saying: "Kan bing nan, kan bing gui," which
roughly translates as "It's difficult and expensive to see a doctor".

This is evident at 8am in the foyer of a hospital in
Kunming, the largest city in Yunnan Province, south-west China. There are
lengthy queues to obtain one of the coveted ‘registration tickets' necessary to
see a doctor, and arguments are breaking out among those who have been lining
up for hours.

This is the frontline of healthcare in China because
there is no primary care gatekeeper system to filter and triage.

Since the early hours, scores of people with minor
ailments have arrived, hoping to claim a place in one of the outpatient
clinics. Many of them are poor families from rural areas, who have come to the
city because they have little faith in their primitive township clinics and
under-trained barefoot doctors.

To see a doctor at a Chinese hospital, you first have
to register and pay a cash deposit. However, the unrest in this morning's
hospital queue has been triggered for another reason.

Because of the value of the registration tickets,
scalpers exploit the economic possibilities and are brazenly working the queue,
reselling tickets for many times their face value. And faced with long and
often unsuccessful waits to get a clinic appointment, there is no shortage of
willing buyers.

This is the reality for China's creaking healthcare
system, which, through a mixture of underfunding and half-baked reforms,
embodies the worst of both communist and capitalist healthcare models — long
waits combined with high cost.

Hospitals are state-owned enterprises that receive
meagre funding from government following the market reforms of the 1990s. The
basic cost of a medical consultation is pegged by law at round 20 yuan ($4).

To cover their operating costs, hospitals resort to a
wide range of surcharges that inflate medical bills. They have also come to
rely on the commissions they charge on medicines, tests and procedures.

While most Chinese citizens are, in theory, covered by
a national health insurance system, in practice, the caps, exclusions and lack
of portability of these policies means that most people still face high
out-of-pocket fees. Healthcare in China is strictly user-pays: no cash, no care.

‘Infusion room' syndrome
All this can create perverse incentives. For instance, the reliance of
hospitals' budgets on drug mark-ups means that there is widespread
overprescribing and overtreatment.

This is evident in the ‘infusion parlour' of the
general medical outpatients clinic of the Kunming hospital.

The large room is filled with rows of seats, along
which sit patients hooked up to IV drips delivering antibiotics or ‘tonics'.
This is the routine first-line treatment for any patient with a fever, cough,
cold or gastro complaint in China.

The hospital charges about 100 yuan ($20) per infusion
— a healthy profit for them but unhealthy for patients who need only simple
analgesics, fluids and rest.

"Hospitals giving infusions for minor illness has
become a long-established bad habit, which is one of the important factors for
antibiotic drug misuse," according to Professor Wu Yunming of Xuzhou
Medical College in Jiangsu Province.

"Hospitals are businesses, and infusions
represent a significant source of revenue for them."

To be fair to China's doctors, it is not individual
greed or ignorance on their part that drives this poor practice.

Chinese doctors know antibiotic infusions are not best
practice for minor illnesses, but infusions have become embedded in routine
care because doctors depend on commissions for about a quarter of their monthly
income.

The basic salary of a hospital resident is about 4000
yuan ($800) a month, equivalent to that of an entry-level public servant or
teacher.

However, their contract includes performance bonuses
of a further 1500 yuan ($300) — the so-called ‘grey income' — which doctors
receive if they meet prescribing quotas in line with the hospital's revenue
targets.

Senior doctors, especially those working in procedural
specialities such as orthopaedics, can make considerably larger sums of money
from commissions.

The government is trying to tackle this
well-recognised cause of overservicing by banning drug commissions and allowing
hospitals to charge higher consultation fees.

However, the early signs from pilot programs carried
out in regional and rural healthcare facilities suggest that hospitals simply
shift from drug mark-ups to additional fees for services.

Violence against doctors
Unsurprisingly, this mix of overservicing and overcharging is a source of
widespread public distrust of doctors and hospitals. The feelings of being
short-changed extend to the short consultation times.

The 80/20 rule, which prohibits GPs from billing 80 or
more services on 20 or more days a year, is used by Medicare in Australia as a
benchmark of poor care. But not so in China, where doctors working in clinics
routinely see 80-100 patients during a four-hour shift.

"I'm so busy I don't even have time for toilet
breaks, let alone lunch. I eat at my desk," one doctor told me during my
visit to the hospital in Kunming last year.

A patient can expect to be with the doctor for about
three minutes — six minutes if they are lucky. The perfunctory nature of such
medical consultations means some patients resort to verbal and physical
aggression to vent their frustration over perceived mistakes or
miscommunication. Violent attacks against medical staff are commonplace.

In a survey by the Chinese Medical Doctor Association,
more than 60% of doctors said they had been subjected to physical abuse and 13%
had been physically assaulted in 2015. That year, there were 115,000 reported
disputes in hospitals with 4600 serious "security incidents" leading
to 1425 arrests.

There have also been several widely reported fatal
attacks against doctors by disgruntled patients or their family members.

The most recent, in early May 2016, saw an emergency
surgeon bludgeoned to death at a Hunan hospital by relatives of a traffic
accident victim. After they were arrested, the assailants claimed the doctor
had "not been vigorous enough" in treating their relative and had
told them to wait their turn, according to Xinhua News Agency.

Such attacks have led to walkouts and public
demonstrations by medical staff calling for authorities to crack down on
violence.

On each occasion, the government has vowed to
"strike hard" against offenders, but aside from ordering hospitals to
hire more security guards, little has been done in reality.

Some doctors have taken to wearing personal protective
gear such as stab-proof vests to work.

Primary care the solution?
China's health ministry is well aware of these problems and has two strategies
to relieve the burden on hospitals: privatisation and primary care.

One of the key healthcare reforms underway in China at
present is a move to bring "social capital" (namely, private
investors) into the hospital sector. To encourage this, the Chinese government
has relaxed laws to allow private operators to set up hospitals, with
pharmaceutical companies taking a lead in the sector.

Just as importantly, China's health ministry has also
eased employment regulations for doctors so that they are no longer tied to
state-owned hospitals and have the freedom to work where they please.

In the past year, there has been a rapid increase in
the number of ‘independent doctor groups' being set up to run private clinic
services — the Chinese equivalent of US groupings such as the Mayo Clinic.

China's second major healthcare reform is a plan to
boost the primary care system. This is a much tougher challenge. The current
‘community clinic' sector is very much an underdeveloped and under-resourced
poor cousin to the culturally prestigious hospital system.

Some of the reasons may sound familiar. Few of China's
doctors are willing to work in community clinics because the pay is poor, the
clinics have little equipment and, unlike the hospital system, there is little
prospect for promotion or career advancement.

China's health ministry has set itself a goal of
having one family practitioner for every 2000 citizens by 2020 (the GP-patient
ratio in Australia is around one FTE GP for every 1080 people).

But to meet this target, China would have to train an
additional 400,000 medical practitioners. The scale of this task can be grasped
by the fact that there are only 170,000 doctors in training, of whom 13,000 are
in the generalist community practitioner training stream.

Primary care pilot projects have been trialled in
China's major cities such as Shanghai and Shenzhen, but with mixed results.

They are declared a success by their proponents, on
the basis of achieving 90% enrolments in their areas. However, there is still a
marked reluctance among the Chinese public to actually use community clinics as
the first port of call. Most still make a beeline for the major hospitals,
which are still seen as the ‘centres of excellence' for medical care.

China's health ministry — like so many Australian
governments — is nevertheless proclaiming that primary care is the way of the
future for healthcare. They have also been mixing carrot-and-stick approaches
to encourage the public to use primary care clinics, such as offering free
consultations, but also making it mandatory to get a GP referral for a hospital
appointment.

The ministry has also ordered that GP training
pathways be set up and requires medical schools to introduce ‘primary care
pathway' training quotas.

Meanwhile, the effects of a medical system that has
embraced the alleged wonders of hospital-based care, can be seen.

Back in the Kunming hospital, by mid-afternoon the
corridors are crammed with patients, hanging about at the doors of the clinics
in the hope that a doctor will "squeeze them in" at the end of their official
list.

But as one doctor told me, "It's too much. I'm
supposed to finish at 5pm but most days I'm here for an extra hour or more. I
am always late for dinner. I studied medicine for eight years and yet I work
longer hours and earn less than a hairdresser."

He adds: "My parents are doctors but I wouldn't
want my child to be a doctor."